GW1-2021-03516_Well Construction - GW1_20210607

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WELL CONSTRUCTION RECORD
For iotemal Use ONLY-
This fonn can be used for single or multiple wells
1
1.Well Contractor Information:
� 14.WATER TONES 1;
Billy Kennedy "a twat TO ar��z -i:aZn
Well Contractor Name a ft &
2834 �
NC well Ca>mactor Certifidatioa N ,` jOi la OUTER cASQrG(far multi smell irrlts oR l II�t da lieaL9e
tC✓ FROM Tor DIAMe R ar�avt_cs MA•tsa.AL
Kennedy Well Drilling �;vn�' , ,�n � ff• 9 fr 16.25 18821 1 Galvanized
Comlraay Nanne r' 0�. 16.INNER CASING OR TUBING fatothernad elose&loo
FROM I TO I DIAMETER MCKNM I MATERIAL
2,Well Crin-ctnaction Permit f R 34—R 4 in, SeA, L10
List all applicable well permin(ze_County,State,Variance,hjecdon eir.)
ff. fL is
3.Well Use(check well user 17.SCREEN
Water Supply Well: FROM TO DIAMETER Slam sir,£ TMCKNFSs MATERIAL
ft. ft in.
OAgricultutal OMunicipal/Public
❑Geothermal(Heating/Cooling Supply) BResidential Water Supply(single) ft IL in
❑Industrial/Commerciai OResidential Water Supply(shared) I&GROUT
FROM TO MATEPJAL EMNACIXENT MET'®OD&AMOUNT
01rri lion Q ft. a0T ft Bentonite Hydrate chips in place
Non-Water Supply Well:
❑Monitoring --� ORecovery, 0 ft J! ff f fneoi
Injection Well: ft ft
OAquifer Recharge OGroundwaterRemediation 19.SAND/GRAY£LPACK ifa "cable
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier fr. ff.
❑Aquifer Test ❑Stormwater Drainage it ft.
❑Experimental Technology OSubsidenceControl
X DRILLING LOG Niaeh additions]sbtets B
OGcother mal(Closed Loop) ❑•Tracer FROM To ntscRmTtorr rotor m,e� saiYrorh n�
OGeothermal(Heatin CoolingRettun) OOiher(explainunder#21Remarks) Q ff yL
4.Irate Well(s)Completed: L Well ID# ft
of R �6�lv✓1 ' 7P U
Jol st Iz / C /Add<
5a.Well Location:
O J l GG tL�
Facllliily/Ownner/Naame / Facility M4(if applicable) ft. ft
'T�TYS Al, 90i/ �Q ft. IL
Physiccid Addddress.City,and Zip 21.RFI%IARES
At iLMC, !
County Parcel Identification No-(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(ifwcll field one L•it/long is safficiera)
N W && �
� Sigoabu citified Well Cantrador Date
6.Is(are)the well(s): tald'ernranenY or ❑Temporary !I},signing#his font,I hereby certify that the tells)was(Were)constructed in accordance
With 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construelion Standards and that a
7.is this a repair to an existing well: DYes or QNo copy of this record has been prarided to the well turner.
If this is a repair,fall out knonm well construction information and explain the nature of the
repair under»21 remarks section or on the back ojthis jorm. 23.Site diagram or additional well details:
I You may use the back of this page to provide additional well site tfetails or well
S.Number of wells constructed: / construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit one faint SUBMITTAL INSTUCTIONS
9.Total well depth'below land surface: 13� (ft) 24a. For Ali WeILc Submit this form within 30 days of completion of well
For muttlple tretis list a0 depths ifdifferenr(example-3(3a 200'mid 2@10W) construction to the following:
10.Static water level below top of casing: 42 (ft.) Division of Water Resources,Information Processing Unit,
Ifirater level is above casing.use"+ 1617 Mail Service Center,Raleigh,NC 27699-1617
IL Borehole diameter: 6.25 (in.) 241b.For Iniection Wells ONLY: In addition to sending the form to the address in
24aabove, also submit a copy of this;form within 30 days of completion of well
12.Well construction method- T��a / -- construction to the following:
(Le.auger,mtaty,cable,direct posh,etc)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mali Service Ceatter,Raleigh,NC 27699-1636
13a.Yield(gpm) .� _ Method of test r r 24a For Water Supply&Injection Wells:
Also submit one copy of this form within 3D days of completion of
13b,Disinfection type: HTH Amount.• ire L well construction to the county health department of the county where
constructed
Form GW-1 North Carolina Dtpmtment ofEnvironment and t4ffitiva]Resoumcs—Division of Wat 1-50HIM s Rmised August 2013
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